Socioeconomic status and bone health in community-dwelling older men: the CHAMP Study

Socioeconomic status influences on bone mineral density in American men: findings from NHANES 2011-2020

The association between socioeconomic status (SES) and bone mineral density (BMD) in men remains controversial. We showed that SES was positively associated with BMD in American men. Confounding factors like race/ethnicity and age could affect the association.

INTRODUCTION

Based on the data from the National Health and Nutrition Examination Survey (NHANES), 2011-2020, this article aims to investigate the association of SES (poverty income ratio (PIR) and education level) with the BMD in American men.

METHODS

We evaluated the association of SES with BMD in 4446 men aged ≥ 20 years (mean age, 41.0 ± 13.4 years) from the NHANES 2011-2020. BMD was measured by dual-energy X-ray absorptiometry (DXA) at the lumbar spine. We used multivariate linear regression models to examine the relationship between SES and total spine BMD, adjusted for a large range of confounding factors.

RESULTS

Compared with other PIR quarters, individuals in the highest quarter of PIR were more likely to be older and white and had fewer smoking or drinking behaviors. After adjusting for race/ethnicity, age, drinking and smoking behavior, body mass index (BMI), total protein, serum calcium, serum uric acid, cholesterol, serum phosphorus, and blood urea nitrogen, PIR was positively correlated with total spine BMD (β = 0.004 95% CI: 0.001-0.007, P = 0.006). Individuals with the highest degree (college degree or above) had a 0.057 g/cm² greater BMD than that of the lowest degree (less than 9th grade) (β = 0.057 95% CI: 0.037-0.077, P < 0.001).

CONCLUSIONS

Our study indicates that SES was positively associated with the lumbar BMD among American men. Clinicians, healthcare providers, and policymakers should consider the unequal SES of men when implementing osteoporosis prevention and treatment strategies.

Engagement in Primary Prevention Program among Rural Veterans With Osteoporosis Risk

A primary osteoporosis prevention program using a virtual bone health team (BHT) was implemented to comanage the care of rural veterans in the Mountain West region of the United States. The BHT identified, screened, and treated rural veterans at risk for osteoporosis using telephone and United States Postal Service communications. Eligibility was determined by regular use of Veterans Health Administration primary care, age 50 or older, and evidence of fracture risk. This study was conducted to identify demographic and clinical factors associated with the acceptance of osteoporosis screening and the initiation of medication where indicated. A cross-sectional cohort design (N = 6985) was utilized with a generalized estimating equation and logit link function to account for facility-level clustering. Fully saturated and reduced models were fitted using backward selection. Less than a quarter of eligible veterans enrolled in BHT's program and completed screening. Factors associated with a lower likelihood of clinic enrollment included being of older age, unmarried, greater distance from VHA services, having a copayment, prior fracture, or history of rheumatoid arthritis. A majority of veterans with treatment indication started medication therapy (N = 453). In this subpopulation, Fisher's exact test showed a significant association between osteoporosis treatment uptake and a history of two or more falls in the prior year, self-reported parental history of fracture, current smoking, and weight-bearing exercise. The BHT was designed to reduce barriers to screening; however, for this population cost and travel continue to limit engagement. The remarkable rate of medication initiation notwithstanding, low enrollment reduces the impact of this primary prevention program, and findings pertaining to fracture, smoking, and exercise imply that health beliefs are an important contributing factor. Efforts to identify and address barriers to osteoporosis screening and treatment, such as clinical factors, social determinants of health, and health beliefs, may pave the way for effective implementation of population bone health care delivery systems. Published 2022. This article is a U.S. Government work and is in the public domain in the USA. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Acculturation and biological stress markers: A systematic review

BACKGROUND

The association of acculturation with health among immigrant populations is believed to be mediated, in part, by acculturation-related stress and stress biology.

OBJECTIVES

To review and qualitatively synthesize empirical findings on the relationship of acculturation with stress-related inflammatory and endocrine biomarkers and composite allostatic load (AL) scores.

METHODS

A literature search was performed in the PubMed and PsycInfo databases. Article titles, abstracts or full-texts were screened and checked for match with the search criteria. Studies were eligible if they empirically tested the relationship between acculturation and inflammatory/endocrine stress biomarkers or composite AL scores, and were published in the English language.

RESULTS

Among the 41 articles identified as relevant and included in this review, the majority were published after 2010, included adult Hispanic U.S.-based populations, used cross-sectional study designs, operationalized acculturation as a unidimensional construct, and varied considerably in the selection of covariates in the analyses. Acculturation was significantly associated with stress biomarkers in 29 studies, but the direction of effects varied across studies. Specifically, acculturation, operationalized as a higher orientation towards the host culture, was associated with inflammatory biomarkers in 10 of 14 studies, with endocrine stress biomarkers in 12 of 20 studies, and with composite AL scores in 7 of 8 studies. Overall, language-based proxy measures of acculturation were related to higher levels of stress-related inflammatory and endocrine biomarkers and to lower levels of AL scores, whereas nativity-, generation status- and length of stay-based proxy measures of acculturation were related to higher levels of inflammatory biomarkers and AL score.

DISCUSSION

The majority of studies reported associations between measures of acculturation and stress biomarkers, however the directions of effects varied across studies. We suggest this heterogeneity may, in part, be a function of limitations imposed by cross-sectional research designs and unidimensional measures of acculturation measures, and we highlight the need for longitudinal studies and use of multidimensional measures of acculturation to better uncover the biobehavioral mechanisms and pathways linking acculturation with health outcomes.

Association of Adult Socioeconomic Status with Body Mass Index: A Within- and Between-Twin Study

Adult socioeconomic status (SES) has been consistently associated with body mass index (BMI), but it is unclear whether it is linked to BMI independently of childhood SES or other potentially confounding factors. Twin studies can address this issue by implicitly controlling for childhood SES and unmeasured confounders. This co-twin control study used cross-sectional data from Twins Research Australia's Health and Lifestyle Questionnaire (N = 1918 twin pairs). We investigated whether adult SES, as measured by both the Index of Relative Socioeconomic Disadvantage (IRSD) and the Australian Socioeconomic Index 2006 (AUSEI06), was associated with BMI after controlling for factors shared by twins within a pair. The primary analysis was a linear mixed-effects model that estimated effects both within and between pairs. Between pairs, a 10-unit increase in AUSEI06 was associated with a 0.29 kg/m2 decrease in BMI (95% CI [-.42, -.17], p < .001), and a 1-decile increase in IRSD was associated with a 0.26 kg/m2 decrease in BMI (95% CI [-.35, -.17], p < .001). No association was observed within pairs. In conclusion, higher adult SES was associated with lower BMI between pairs, but no association was observed within pairs. Thus, the link between adult SES and BMI may be due to confounding factors common to twins within a pair.

Socioeconomic status, health-related behaviours, and death among older people: the Concord health and aging in men project prospective cohort study

Background

Conflicting evidence exists regarding the association of socioeconomic status (SES) with mortality among older people and little is known about the mechanisms underlying this association. We investigated the association of SES with mortality among older Australian men. We also investigated potential mediating effects of health-related behaviours in SES-mortality associations.

Methods

We used data from a prospective population-based cohort (the Concord Health and Aging in Men Project), in Sydney, Australia. The main outcomes were all-cause and cause-specific mortality. Educational attainment, occupational position, source of income, housing tenure, and a cumulative SES score were assessed at baseline. Longitudinally assessed alcohol consumption, smoking, physical activity, and body mass index were investigated as potential mediators. Associations were quantified using Cox regression.

Results

We evaluated 1527 men (mean age: 77.4 ± 5.5 years). During a mean follow-up time of 9.0 years, 783 deaths occurred. For deaths from all causes, the adjusted hazard ratio (HR) for the lowest tertile of cumulative SES score versus the highest tertile was 1.44 (95% CI 1.21 to 1.70); the corresponding sub-HRs were 1.35 (0.96 to 1.89) for cardiovascular disease (CVD) mortality; 1.58 (1.15 to 2.18) for cancer mortality, and 1.86 (1.36 to 2.56) for non-CVD, non-cancer mortality. SES-mortality associations were attenuated by 11–25% after adjustment for mediating health-related behaviours.

Conclusion

Low SES is associated with increased mortality in older Australian men and health-related behaviours accounted for less than one-fourth of these associations. Further research is needed to fully understand the mechanisms underlying SES inequalities in mortality among older people.

Estimation of Prevalence of Osteoporosis Using OSTA and Its Correlation with Sociodemographic Factors, Disability and Comorbidities

Osteoporosis is a growing concern for an aging society. The study aimed to estimate the prevalence of older adults who were at risk of osteoporosis and explore factors associated with osteoporosis. The relationship between the risk of osteoporosis, chronic conditions and disability was also explored. We hypothesized that respondents with high risk index of osteoporosis would be associated with greater disability. Participants aged 60 years and above (N = 2565) who were representative of Singapore’s multiethnic population were recruited. The Osteoporosis Self-Assessment Tool for Asians (OSTA) was used to classify the risk of osteoporosis. Information on sociodemographic details and chronic diseases were collected, while severity of disability was measured using the World Health Organization Disability Assessment Schedule 2.0. The overall prevalence of the respondents who were at risk of osteoporosis was 52%. Those belonging to an older age, Chinese, female, never married or widowed, lower education and retired were associated with a higher risk of osteoporosis. A diagnosis of diabetes or hypertension was a protective factor against the risk of osteoporosis. High risk of osteoporosis was not associated with disability. Our findings highlighted specific factors associated with the risk of osteoporosis that could be useful for the prevention of osteoporosis and fractures.

Contingent association between the size of the social support network and osteoporosis among Korean elderly women

OBJECTIVE

To investigate the association between the number of personal ties (or the size of the social support network) and the incidence of osteoporosis among older women in Korea.

METHODS

Data from the Korean Urban Rural Elderly Study were used. Bone density was measured by dual-energy X-ray absorptiometry at the lumbar spine (L1-L4) and femur neck. T-score, the standardized bone density compared with what is normally expected in a healthy young adult, was measured and the presence of osteoporosis was determined, if the T-score was < -2.5. The social support network size was measured by self-responses (number of confidants and spouse).

RESULTS

Of the 1,846 participants, 44.9% were diagnosed with osteoporosis. The association between the social support network size and the incidence of osteoporosis was curvilinear in both bivariate and multivariate analyses. Having more people in one's social support network size was associated with lower risk of osteoporosis until it reached around four. Increasing the social support network size beyond four, in contrast, was associated with a higher risk of osteoporosis. This association was contingent on the average intimacy level of the social network. At the highest average intimacy level ("extremely close"), increasing the number of social support network members from one to six was associated with linear decrease in the predicted probability of osteoporosis from 45% to 30%. However, at the lowest average intimacy level ("not very close"), the predicted probability of osteoporosis dramatically increased from 48% to 80% as the size of the social network increased from one to six.

CONCLUSION

Our results show that maintaining a large and intimate social support network is associated with a lower risk of osteoporosis among elderly Korean women, while a large but less-intimate social relationship is associated with a higher risk.

Socioeconomic disparities in osteoporosis prevalence: different results in the overall Korean adult population and single-person households

OBJECTIVES

The present study was conducted in order to examine the association between socioeconomic status (SES) and osteoporosis prevalence in Korea and to assess whether different associations are found in single-person households.

METHODS

A cross-sectional population-based study was conducted using the Korea National Health and Nutrition Examination Survey, from 2008 to 2011. The study subjects were people aged ≥ 50 years with osteoporosis as defined by bone mineral density. Multivariate logistic models were used to estimate prevalence odds ratios (pORs) and 95% confidence intervals (CIs). Gender differences in the likelihood of osteoporosis were analyzed based on household income, education level, and residential area.

RESULTS

There were 8221 osteoporosis patients aged ≥ 50 years, of whom 927 lived in single-person households. There was a gender-specific association between osteoporosis prevalence and all three SES factors that we analyzed: income, education, and residential area. After adjusting for age, SES, and health behaviors, including body mass index (BMI), low household income was only significantly associated with osteoporosis in men, whereas education level had an inverse relationship with osteoporosis only in women (p = 0.01, p < 0.001, respectively). However, after controlling for age and BMI, rural residency was only associated with osteoporosis in women living in single-person households (pOR, 1.59; 95% CI, 1.05 to 2.43).

CONCLUSIONS

The Korean adult population showed a gender-specific relationship between SES and osteoporosis prevalence, with a different pattern found in single-person households.

The relationship between socioeconomic status and fracture in a fracture clinic setting: data from the Nottingham Fracture Liaison Service

BACKGROUND

This study aims to better understand the relationship between socioeconomic status (SES), fractures in those that attend an outpatient fracture clinic and a diagnosis of osteoporosis. This will further aid our ability to risk stratify patients' with fractures for further investigation and secondary management of their bone health.

METHOD

This is a cross sectional analysis using data from the Nottingham Fracture Liaison Service of patients attending the outpatient fracture clinic from 1/01/08 to 31/12/11. Logistic regression adjusted for age and gender were used to investigate SES, fractures and a diagnosis of osteoporosis. Fisher's exact test was used to compare DXA attendance in those living in most deprived and least deprived area. A cut off of 65 years was used to conduct subset analysis of a younger and an older group.

RESULTS

6362 patients (1346 male, 5016 female; mean (SD) age, 69 (12)) were included in the study. There was no relationship between SES, proportion of fracture types and having a diagnosis of osteoporosis. Prevalence of osteoporosis in each SES quintile from 1 (most deprived) to 5 (least deprived) was 26.68%, 29.04%, 24.83%, 25.67% and 26.68% respectively. The least deprived quintile compared with the most deprived was not associated with a diagnosis of osteoporosis (OR 0.97; 95% CI 0.76-1.25, p=0.837). Those living in the most deprived area were less likely to attend their bone density scan appointment compared to those living in the least deprived area (OR 0.56; 95% CI 0.44-0.7, p<0.0001).

CONCLUSION

This study has shown that there is no relationship between SES, fracture types and a diagnosis of osteoporosis in those that present to the fracture clinic. SES should not be used to risk stratify patients for further bone health management after fractures. Those living in the most deprived areas are less likely to attend their bone density scan and efforts need to be made to improve attendance in this group.

Racial/ethnic and socioeconomic differences in bone loss among men

As men age, they lose bone and are susceptible to fracture. Despite having lower fracture rates than women, men have worse fractures than women do. Racial/ethnic and socioeconomic status (SES) disparities in fracture rates exist, yet data on rates of bone loss by race/ethnicity and SES among men are limited. We examined annualized percentage change in bone mineral density (%ΔBMD) at the hip (N = 681), spine (N = 663), and forearm (N = 636) during 7 years of follow-up among men aged 30-79 years at baseline. Multivariable models tested whether race/ethnicity, income, or genetic ancestry predicted annualized %ΔBMD after controlling for an extensive set of covariates. Annualized %ΔBMD ranged from -0.65(0.04)% (femoral neck) to +0.26(0.03)% (1/3 distal radius), and changes were consistent across age groups with the exception of the ultradistal radius, where annualized declines increased with age. Neither self-identified race/ethnicity nor genetic ancestry were associated with annualized %ΔBMD. In contrast, income was strongly associated (dose-response) with annualized %ΔBMD at total hip (independent of confounders, self-identified race/ethnicity, and genetic ancestry). Fully adjusted least-square mean change in annualized %ΔBMD at the total hip were -0.24(0.12)% and -0.16(0.06)% steeper among men with low and moderate incomes, respectively, than among men with higher incomes (overall p = 0.0293). Results show a linear decline in bone that begins relatively early in life among men, that rates of bone loss do not vary with race/ethnicity (self-identified or "objectively" measured), and that income plays an important role in relation to bone loss at the hip. These data suggest that fracture risk in men may be driven in part by income-related differences in bone loss, but also, that the known higher fracture risk among white men is not the result of racial/ethnic differences in bone loss, but rather, early life exposures that lead to attainment of higher peak bone mass among minorities.

Marital histories, marital support, and bone density: findings from the Midlife in the United States Study

We examined the association between marital life history and bone mineral density (BMD) in a national sample from the US. In men, being stably married was independently associated with better lumbar spine BMD, and in women, more spousal support was associated with better lumbar spine BMD.

INTRODUCTION

Adult bone mass may be influenced by stressors over the life course. We examined the association between marital life history and bone mineral density (BMD) net socioeconomic and behavioral factors known to influence bone mass. We sought evidence for a gender difference in the association between marital history and adult BMD.

METHODS

We used data from 632 adult participants in the Midlife in the United States Study to examine associations between marital history and BMD, stratified by gender, and adjusted for age, weight, menopausal stage, medication use, childhood socioeconomic advantage, adult financial status, education, physical activity, smoking, and alcohol consumption.

RESULTS

Compared to stably married men, men who were currently divorced, widowed, or separated, men who were currently married but previously divorced, widowed, or separated, and never married men had 0.33 (95% CI: 0.01, 0.65), 0.36 (95% CI: 0.10, 0.83), and 0.53 (95% CI: 0.23, 0.83) standard deviations lower lumbar spine BMD, respectively. Among men married at least once, every year decrement in age at first marriage (under age 25) was associated with 0.07 SD decrement in lumbar spine BMD (95% CI: 0.002, 0.13). In women, greater support from the spouse was associated with higher lumbar spine BMD.

CONCLUSIONS

Our findings suggest that marriage before age 25 and marital disruptions are deleterious to bone health in men, and that marital quality is associated with better bone health in women.

Influence of education, marital status, occupation, and the place of living on skeletal status, fracture prevalence, and the course and effectiveness of osteoporotic therapy in women in the RAC-OST-POL Study

The RAC-OST-POL population-based, epidemiological study provided data concerning the influence of education, marital status, occupation, and the place of living (residence) on skeletal status, fracture prevalence, and the course and effectiveness of osteoporotic therapy in 625 women older than 55 years, all of them recruited from the District of Raciborz in Poland. Their mean age was 66.4 ± 7.8 years. All the women completed a specially designed questionnaire. The skeletal status was assessed by femoral neck (FN) and total hip (TH) densitometry, using a Lunar DPX system (USA). In univariate analyses, taking into consideration the age differences, bone mineralization was dependent on marital status (Z score for FN and TH was significantly higher in widows than in divorcees; p < 0.05), place of residence (better results in rural areas; p < 0.05), and occupation (better in standing than sitting jobs; p < 0.05 for FN Z score and p < 0.01 for TH Z score). The multivariate model allowed us to verify that only place of living and type of occupation had a significant influence on densitometry results. In direct comparison, fracture prevalence seemed to be borderline significantly more common in widows (33.5%) and least common among divorcees (11.8%) (χ(2) = 6.9, df = 3, p = 0.07), but reanalysis performed after age adjustment excluded a true impact of marital status on fracture occurrence. Other factors did not affect fracture occurrence. Some factors influenced the use of medications for osteoporosis: higher level of education was associated with a more frequent use of vitamin D (χ(2) = 8.49, df = 3, p < 0.05) and of hormone replacement therapy (HRT) (χ(2) = 35.7, df = 3, p < 0.00001). HRT was most commonly used by unmarried women (30%) and least commonly by divorcees (11.8%) (χ(2) = 11.7, df = 3, p = 0.01). Vitamin D was more often used among women from the urban area of Raciborz than by those from surrounding rural areas (χ(2) = 9.2, df = 1, p < 0.01). The frequency of use of the three aforementioned medications was associated with the character of occupation. Women with sedentary jobs demonstrated the highest frequency of intake for vitamin D (χ(2) = 9.92, df = 3, p < 0.05) and HRT (χ(2) = 19.48, df = 3, p < 0.001) as well as for other antiresorptive medications (χ(2) = 8.18, df = 3, p < 0.05). We concluded that the results of the epidemiological study demonstrate that both skeletal status and use of antiosteoporotic medications were partially modified by analyzed social factors, whereas fracture prevalence was generally independent from those factors. These data suggest that education, marital status, place of living, and type of occupation may have impacts on implementation of osteoporosis-preventing health programs.

Childhood socioeconomic status and adult femoral neck bone strength: findings from the Midlife in the United States Study

PURPOSE

Bone acquisition in childhood impacts adult bone mass, and can be influenced by childhood socioeconomic conditions. Socioeconomic status is also associated with body weight which affects the load that bone is exposed to in a fall. We hypothesized that socioeconomic advantage in childhood is associated with greater bone strength relative to load in adulthood.

METHODS

Hip dual x-ray absorptiometry scans from 722 participants in the Midlife in the United States Study were used to measure femoral neck size and bone mineral density, and combined with body weight and height to create composite indices of femoral neck strength relative to load in different failure modes: compression, bending, and impact. A childhood socioeconomic advantage score was created for the same participants from parental education, self-rated financial status relative to others, and not being on welfare. Multiple linear regression was used to determine the association of childhood socioeconomic advantage with femoral neck composite strength indices, stratified by gender and race (white/non-white), and adjusted for study site, age, menopause status in women, education, and current financial advantage.

RESULTS

Childhood socioeconomic advantage was independently associated with higher indices of all three composite strength indices in white men (adjusted standardized effect sizes, 0.19 to 0.27, all p values<0.01), but not in the other three race/gender groups. Additional adjustment for adult obesity, physical activity in different life stages, smoking, and heavy drinking over the life-course significantly attenuated the associations in white men.

CONCLUSIONS

Socioeconomic disadvantage in childhood is associated with lower hip strength relative to load in white men, and these influences are dampened by healthy lifestyle choices.

The effect of socioeconomic position on bone health among Koreans by gender and menopausal status

While studies suggest that socioeconomic position (SEP) influences bone health and risk of osteoporotic fracture in postmenopausal women, few studies have simultaneously examined gender and menopause differences as they relate to SEP and bone health. Here, we investigated the relationship between SEP and bone mineral density (BMD) among Korean men, premenopausal women, and postmenopausal women using the BMD data set (n = 9,995) of the Korean National Health and Nutrition Examination Survey IV. The relationship between SEP and BMD was estimated using analysis of covariance (ANCOVA); adjustments were made for age and body mass index (BMI) in the multivariate models. The relationship between SEP and osteoporosis prevalence was estimated using logistic regression. Relative index of inequality (RII) in osteoporosis was estimated using log-binomial regression. ANCOVA (adjusted for age and for age plus BMI) showed a significant positive association between SEP and BMD among men and postmenopausal women. Logistic regression showed a significant negative association between SEP and osteoporosis prevalence among men and postmenopausal women but not in premenopausal women. The RII, estimated by log-binomial regression, showed the impact of SEP on osteoporosis to be significant in men and postmenopausal women (p < 0.05) but not in premenopausal women. Overall, low SEP was associated with both low BMD and high risk of osteoporosis among men and postmenopausal women. Efforts to reduce the economic burden of morbidity and mortality from osteoporosis should target men and postmenopausal women with low SEP.

Quality of life in older outpatients living alone in the community in Italy

There is limited knowledge on the relationship between the living conditions of community-dwelling older people and their quality of life (QOL) considered in all its specific domains. The purpose of this study was to determine (1) which dimensions of QOL were independently associated with living alone and (2) the independent correlates of these dimensions of QOL amongst older outpatients. We conducted a cross-sectional survey of 239 community-dwelling outpatients aged 65+ (mean age 81.5 years) consecutively referred to a geriatric medicine clinic in Italy between June and November 2009 (response rate 93%). Subjects underwent a comprehensive geriatric assessment including QOL, which was evaluated by using the Older People's QOL questionnaire. In multivariate logistic regression analyses, living alone was associated with the lowest score-based tertile of two specific dimensions of QOL out of seven, namely 'social relationships and participation' [odds ratio (OR) 2.73, 95% confidence interval (CI) 1.08-6.91] and 'home and neighbourhood' (OR 4.96, 95% CI 1.75-14.07), independently of the main demographic, social, functional and clinical characteristics of the subjects. Amongst the 107 subjects living alone, independent correlates of these dimensions of QOL were depression, having no caregiver and having never been married. Depression, having no caregiver and having never been married could provide a valuable means of identifying older people living alone who are at greater risk of a poor QOL and who would most benefit from effective social and medical interventions.